Medicare’s National Coverage Decisions For Technologies, 1999–2007

Paying for Frequent Dialysis

In late 2017, the 7 regional contractors responsible for paying dialysis claims in Medicare proposed new payment rules that would restrict payment for hemodialysis treatments in excess of 3 weekly to exceptional acute-care circumstances. Frequent hemodialysis is performed more frequently than the traditional thrice-weekly pattern, and many stakeholders-patients, providers, dialysis machine manufacturers, and others-have expressed concern that these payment rules will inhibit the growth of this treatment modality's use among US dialysis patients. In this Perspective, we explain the role of these contractors in the context of Medicare's in-center hemodialysis-centric dialysis payment system and assess how well this system accommodates the higher treatment frequencies of both peritoneal dialysis and frequent hemodialysis. Then, given the available evidence concerning the relative effectiveness of these modalities versus thrice-weekly in-center hemodialysis and trends in their use, we discuss options for modifying Medicare's payment system to support frequent dialysis.

Evaluation of technologies approved for supplemental payments in the United States

Supplemental payment programmes can increase access to new technologies, but Timothy Judson and colleagues find that some payments are made without clear evidence of safety and effectiveness

Barriers to Ensuring Access to Affordable Prescription Drugs

High and rising prescription drug costs have become a preoccupying policy problem in the United States. Notwithstanding broad, bipartisan interest in finding effective policy solutions, several aspects of the drug affordability problem make it an uncommonly difficult one to solve. This article reviews the moral, market, and political factors contributing to the difficulty. Among the moral problems is lack of agreement about how to weigh the fundamental tradeoff involved in regulating drug prices-affordability versus incentives for innovation-and about what constitutes a fair price. Market-related factors include the lack of price transparency and a myriad of perverse incentives in the system through which prescription drugs are supplied to patients. Finally, current policy choices are constrained by past political compromises, and an atmosphere of scandal focusing on egregious instances of price gouging has made rational deliberation about fixes to deeper problems in the system difficult.

Evidence supporting FDA approval and CMS national coverage determinations for novel medical products, 2005 through 2016: A cross-sectional study

Food and Drug Administration (FDA) and Centers for Medicare and Medicaid Services (CMS) rely on evidence from clinical trials when approving a therapeutic for marketing and insurance coverage in the US, respectively. No study has compared the quality and quantity of evidence examined by these agencies.To characterize evidence used by FDA and CMS to support marketing approval and National Coverage Determinations (NCDs), respectively, of novel therapeutics reviewed for CMS coverage from 2005 through 2016.A cross-sectional study of clinical trials described in FDA approval documents and CMS NCD memoranda. We compared the number of clinical trials used by each agency as well as the following characteristics among original clinical trials: study size, randomization, double-blinding, and control arm.Twelve medical products met our inclusion criteria. FDA approvals of these products were based on 22 pivotal trials. CMS NCDs were based on 27 original clinical trials; 14 clinical trials were used by both agencies. Between FDA pivotal and CMS original clinical trials, there was no significant difference in study size (P = .53), use of randomization (P = .75), double-blinding (P = .55), or control arm (P = .54). There was no statistically significant difference in median age between participants in trials reviewed by CMS versus those reviewed by FDA (62 vs 59 years, P = .26). The median time from FDA approval to publication of CMS NCD memorandum was 17 (interquartile range, 13-36) months.FDA approvals and CMS NCDs are based on a similar number and quality of trials, although trial participants are not reflective of the Medicare population, and the process of finalizing coverage determinations requires an additional 17 months.

Healthcare quality and medicine reimbursement criteria in Iran

Purpose

This study aims to measure the quality of services provided to elderly people at the most crowded governmental ambulatory clinics of Tehran Province using the SERVQUAL scale (Study 1). Moreover, the research indicates the medicine reimbursement criteria to inform the decision-makers of public health insurance organizations using the Borda method (Study 2).

Design/methodology/approach

This study was done as a cross-sectional research on 425 elderly patients who came to the clinics during 2014 and 2015. Finally, using the paired t-test, Friedman test, Borda method, SPSS, Matlab software and Delphi method, the collected data were analysed.

Findings

Regarding the perceived quality, the services assurance dimension was ranked as having the highest quality (4.48) and the accessibility dimension as the lowest one (3.22). Based on the Borda method, the most important criterion for the Iranian health insurance companies to accept a medicine in their reimbursement list is the “life-threatening conditions” factor. On the other hand, “evidence quality” is accounted as the fifth important factor.

Research limitations/implications

The main limitation was the senility of participants that makes it difficult for understanding and completing the questionnaires.

Practical implications

The results can be useful for healthcare policy makers and related authorities. Besides, public health insurers can use the findings for decision-making about the elderly diseases and the problems such as the medical expenses.

Originality/value

The present research has been done in a two-year time frame, and it is more recent than other related studies. Thus, the results are far more authentic and applicable.

Performance-Based Risk-Sharing Arrangements: An Updated International Review

Enthusiasm for performance-based risk-sharing arrangements (PBRSAs) continues but at variable pace across countries. Our objective was to identify and characterize publicly available cases and related trends for these arrangements. We performed a review of PBRSAs from 1993 to 2016 using the University of Washington PBRSA Database. Arrangements were categorized according to a previously published taxonomy. Macro-level trends were identified related to the timing of adoption, countries involved, types of arrangements, and disease areas. Our search yielded 437 arrangements. Among these, 183 (41.9%) were categorized as currently active, while 58.1% have expired. Five main types of arrangements have been identified, namely coverage with evidence development (149 cases, 34.1%), performance-linked reimbursement (104 cases, 23.8%), conditional treatment continuation (78 cases, 17.8%), financial or utilization (71 cases, 16.2%), and hybrid schemes with multiple components (35 cases, 8.0%). The pace of adoption varies across countries but has renewed an upward trend after a lull in 2012/2013. Conditions in the USA may be changing toward a more favorable environment of PBRSAs. Interest in PBRSAs remains high, suggesting they are a viable coverage and reimbursement mechanism for a wide range of medical products.

Persistent Variation in Medicare Payment Authorization for Home Hemodialysis Treatments

OBJECTIVE

To analyze variation in medical care use attributable to Medicare's decentralized claims adjudication process as exemplified in home hemodialysis (HHD) therapy.

DATA SOURCES/STUDY SETTING

Secondary data analysis using 2009-2012 paid Medicare claims for HHD and in-center hemodialysis (IHD).

STUDY DESIGN

We compared variation across Medicare administrative contractors (MACs) in predicted paid treatments per standardized patient-month for HHD and IHD patients. We used ordinary least-squares regression to determine whether higher paid HHD treatment counts expanded HHD programs' presence among dialysis facilities.

DATA COLLECTION

We identified HHD and IHD treatments using procedure, revenue center, and claim condition codes on type 72x claims.

PRINCIPAL FINDINGS

MACs varied persistently in predicted HHD treatments per patient-month, ranging from 14.3 to 21.9 treatments versus 10.9 to 12.4 IHD treatments. The presence of facilities' HHD programs was uncorrelated with average HHD payment counts.

CONCLUSIONS

Medicare's claims adjudication process promotes variation in medical care use, as we observe among HHD patients. MACs' discretionary decision making, while potentially facilitating innovation, may admit inefficiency in care practice as well as inequitable access to health care services. Regulators should weigh the benefits of flexibility in local coverage decisions against those of national standards for medical necessity.

Medicare is scrutinizing evidence more tightly for national coverage determinations

We examined Medicare national coverage determinations for medical interventions to determine whether or not they have become more restrictive over time. National coverage determinations address whether particular big-ticket medical items, services, treatment procedures, and technologies can be paid for under Medicare. We found that after we adjusted for the strength of evidence and other factors known to influence the determinations of the Centers for Medicare and Medicaid Services (CMS), the evidentiary bar for coverage has risen. More recent coverage determinations (from mid-March 2008 through August 2012) were twenty times less likely to be positive than earlier coverage determinations (from February 1999 through January 2002). Furthermore, coverage during the study period was increasingly and positively associated both with the degree of consistency of favorable findings in the CMS reviewed clinical evidence and with recommendations made in clinical guidelines. Coverage policy is an important payer tool for promoting the appropriate use of medical interventions, but CMS's rising evidence standards also raise questions about patients' access to new technologies and about hurdles for the pharmaceutical and device industries as they attempt to bring innovations to the market.

Medicare and Amyloid PET Imaging: The Battle Over Evidence

We examine a recent dispute regarding the Centers for Medicare and Medicaid Services' (CMS) refusal to unconditionally pay for amyloid positron emission tomography (PET) imaging for Medicare beneficiaries being assessed for Alzheimer's disease. CMS will only pay for amyloid PET imaging when patients are enrolled in clinical trials that meet certain criteria. The dispute reflects CMS's willingness in certain circumstances to require effectiveness evidence that differs from the Food and Drug Administration's standard for pre-market approval of a medical intervention and reveals how stakeholders with differing perspectives about evidentiary standards have played a role in attempting to shape the Medicare program's coverage policies.

CHANGING FACE OF MEDICARE'S NATIONAL COVERAGE DETERMINATIONS FOR TECHNOLOGY

OBJECTIVES

The Centers for Medicare and Medicaid Services (CMS) issues National Coverage Determinations (NCDs) for medical interventions expected to have a significant impact on Medicare, the health insurance program for US citizens aged 65 years and older and certain people with disabilities under the age of 65 years. The objective of this study was to evaluate NCDs issued from 1999 to 2013 to identify key trends, and to discuss implications for future CMS policy.

METHODS

We used the Tufts Medical Center Medicare National Coverage Determination Database to examine characteristics of NCDs from 1999 through 2013. We examined various characteristics of NCDs, including: whether the intervention under review is used for prevention or treatment of disease, the type of intervention considered, evidence limitations cited by CMS, and coverage determination outcome. We evaluated longitudinal trends in categorical and continuous variables in the database, using Cochran-Armitage trend tests and linear regression, respectively.

RESULTS

We found that NCDs increasingly focus on preventive care (p = 0.072), pertain to diagnostic imaging (p = 0.033), and evaluate health education/behavioral therapy interventions (p = 0.051). CMS increasingly cites the lack of relevant outcomes (p = 0.019) and the lack of applicability of study results to the Medicare population (p < 0.001) as evidence limitations. CMS less often restricts coverage to certain population subgroups in NCDs (p < 0.001), but increasingly applies coverage with evidence development policies (p < 0.001).

CONCLUSIONS

Identified trends reflect broader changes in Medicare as CMS shifts its focus from treatment to prevention of disease, addresses potentially overutilized technologies, and attempts to issue flexible coverage policies.

Medicare's use of cost-effectiveness analysis for prevention (but not for treatment)

CONTEXT

Medicare currently pays for 23 preventive services in its benefits package, the majority of which were added since 2005. In the past decade, the program has transformed from one essentially administering treatment claims, to one increasingly focused on health promotion and maintenance. What is largely unappreciated is the role cost-effectiveness analysis has played in the coverage of preventive services.

METHODS

We review the role of cost-effectiveness analysis in Medicare coverage of preventive services and contrast it to the lack of such consideration in the coverage of treatments.

FINDINGS

While not considered for coverage of treatment, cost-effectiveness analysis played a role in the coverage of nine preventive services, and was evaluated in a number of instances when the service was not added. Pneumococcal vaccine, the first preventive service added to the benefit (1981), followed a Congressionally requested cost-effectiveness analysis, which showed it to be cost-saving. More recently, the Centers for Medicare and Medicaid Services (CMS) reviewed cost-effectiveness evidence when covering preventive services such as HIV screening (2010) and screening and behavioral counseling for alcohol misuse (2011) (studies reported cost-effectiveness ratios of $55,440 per QALY, and $1755 per QALY, respectively).

CONCLUSIONS

Cost-effectiveness analysis has played a longstanding role in informing the addition of preventive services to Medicare. It offers Medicare officials information they can use to help ensure health gains are achieved at reasonable cost. However, limiting cost-effectiveness evidence to prevention and not treatment is inconsistent and potentially inefficient.

Impact of alternative medical device approval processes on costs and health

BACKGROUND

Medical devices are often introduced prior to randomized-trial evidence of efficacy and this slows completion of trials. Alternative regulatory approaches include restricting device use outside of trials prior to trial evidence of efficacy (like the drug approval process) or restricting out-of-trial use but permitting coverage within trials such as Medicare's Coverage with Study Participation (CSP).

METHODS

We compared the financial impact to manufacturers and insurers of three regulatory alternatives: (1) limited regulation (current approach), (2) CSP, and (3) restrictive regulation (like the current drug approval process). Using data for patent foramen ovale closure devices, we modeled key parameters including recruitment time, probability of device efficacy, market adoption, and device cost/price to calculate profits to manufacturers, costs to insurers, and overall societal impact on health.

RESULTS

For manufacturers, profits were greatest under CSP-driven by faster market adoption of effective devices-followed by restrictive regulation. Societal health benefit in total quality-adjusted life years was greatest under CSP. Insurers' expenditures for ineffective devices were greatest with limited regulation. Findings were robust over a reasonable range of probabilities of trial success.

CONCLUSIONS

Regulation restricting out-of-trial device use and extending limited insurance coverage to clinical trial participants may balance manufacturer and societal interests.

Medicare covers the majority of FDA-approved devices and Part B drugs, but restrictions and discrepancies remain

The Food and Drug Administration (FDA) and Medicare use different standards to determine, first, whether a new drug or medical device can be marketed to the public and, second, if the federal health insurance program will pay for use of the drug or device. This discrepancy creates hurdles and uncertainty for drug and device manufacturers. We analyzed discrepancies between FDA approval and Medicare national coverage determinations for sixty-nine devices and Part B drugs approved during 1999-2011. We found that Medicare covered FDA-approved drugs or devices 80 percent of the time. However, Medicare often added conditions beyond FDA approval, particularly for devices and most often restricting coverage to patients with the most severe disease. In some instances, Medicare was less restrictive than the FDA. Our findings highlight the importance for drug and device makers of anticipating Medicare's needs when conducting clinical studies to support their products. Our findings also provide important insights for the FDA's and Medicare's pilot parallel review program.

Evolving reimbursement and pricing policies for devices in Europe and the United States should encourage greater value

Rising health care costs are an international concern, particularly in the United States, where spending on health care outpaces that of other industrialized countries. Consequently, there is growing desire in the United States and Europe to take a more value-based approach to health care, particularly with respect to the adoption and use of new health technology. This article examines medical device reimbursement and pricing policies in the United States and Europe, with a particular focus on value. Compared to the United States, Europe more formally and consistently considers value to determine which technologies to cover and at what price, especially for complex, costly devices. Both the United States and Europe have introduced policies to provide temporary coverage and reimbursement for promising technologies while additional evidence of value is generated. But additional actions are needed in both the United States and Europe to ensure wise value-based reimbursement and pricing policies for all devices, including the generation of better pre- and postmarket evidence and the development of new methods to evaluate value and link evidence of value to reimbursement.

Towards an expanded definition of value

Much of the change being sought in the United State's health-care system is predicated on improving value. Value is most simply defined as quality divided by cost, and physicians increasingly rely on the quality-adjusted life year as the numerical measure to justify their services. However, there are many other definitions of value being advocated by various stakeholders in the health-care reform effort. Incentive programs and pilot studies implemented by private and public payers are steering much of the current change. Expanding our understanding of how value is defined by health-care economists and policy makers can help spine providers navigate the evolving health-care landscape.

Median approval times for class III medical devices have been well above statutory deadlines set for FDA and CMS

The Food and Drug Administration (FDA) and the Centers for Medicare and Medicaid Services (CMS) play key roles in making safe and effective medical devices available to the public. Since 1997 Congress has passed "modernization" laws that specify statutory deadlines for these agencies to review manufacturers' applications for premarket approval--the process by which the FDA evaluates the safety and effectiveness of class III medical devices, those that pose the highest risk--and applications for national coverage by Medicare. We questioned whether these reforms shortened approval time at the FDA and CMS. We searched publicly available databases for information for the period from January 1, 1995, through December 31, 2008, and calculated median time to approval. After initially declining, the FDA median approval time increased after 2002 and nearly reached the 1997 prereform levels by the end of the study period. In contrast, the CMS median approval time decreased steadily over the period. Neither agency consistently met the statutory deadline of 180 days for approval of premarket applications or national coverage. Congress should consider the underlying causes for these delays in the development of future modernization legislation.

Therapies for advanced cancers pose a special challenge for health technology assessment organizations in many countries

Health technology assessment organizations evaluate medical therapies and technologies to help inform coverage and reimbursement decisions for payers around the globe. Even as they establish strict review processes, these organizations--and the reimbursement authorities that use their assessments--have sometimes handled cancer interventions with special care. We found that some countries have created separate health technology assessment pathways for cancer treatment, while others have eased access to cancer treatments through end-of-life or disease-severity exceptions within health technology assessment policies. In the United States, although no separate evaluation pathways exist for cancer, cancer drugs receive special status by virtue of unique Medicare rules covering off-label indications. Worldwide, we demonstrate that health technology assessment organizations are struggling with cancer's "exceptionalism."

Medicare's national coverage determinations in diagnostic radiology: examining evidence and setting limits

OBJECTIVE

To systematically review and summarize the Center for Medicare and Medicaid Services (CMS) national coverage determination (NCDs) pertaining diagnostic imaging technologies from 1999 through 2010.

METHODS

All NCDs pertaining to diagnostic imaging were identified from the Tufts Medical Center NCD database. The variables under study included the quality of the clinical evidence and the final coverage determination. The types of restrictions were categorized. We also categorized the final decisions as "positive coverage" or "no positive/no change in coverage" and assessed the correlation between positive coverage and other variables using Fisher exact test.

RESULTS

Twenty-two of 152 (15%) NCDs pertained to diagnostic imaging technologies. The supporting evidence was judge to be good, fair, and poor in 5, 6, and 11 cases, respectively. Eleven technologies (50%) were covered with conditions, four (18%) deferred the coverage decision to local level, and two (9%) were completely not covered. In five instances there was no change to the prior coverage status. Of the 11 decisions resulting in positive coverage, 8 (73%) restricted use to specific population subgroups, 5 (46%) applied restrictions related to treatment, 4 were covered with evidence development, and 2 were restricted to care in specific settings. A significantly higher rate of positive coverage decisions was achieved if the available evidence was good (100% 5/5) or fair (83% 5/6) compared to technologies with poor evidence (10% 1/10) (P < .01).

CONCLUSION

CMS has demonstrated a propensity to limit the use of advanced diagnostic imaging to scenarios in which appropriateness is supported by adequate evidence of clinical utility and improved outcomes with the quality of evidence being a significant factor on final decisions. Understanding the need for high-quality evidence and the types of limitations placed on coverage allows for appropriate planning for the incorporation of diagnostic imaging technologies into clinical practice.

Principles for planning and conducting comparative effectiveness research

Aims: To develop principles for planning and conducting comparative effectiveness research (CER). Methods: Beginning with a modified existing list of health technology assessment principles, we developed a set of CER principles using literature review, engagement of multiple experts and broad stakeholder feedback. Results & conclusion: Thirteen principles and actions to fulfill their intent are proposed. Principles include clarity of objectives, transparency, engagement of stakeholders, consideration of relevant perspectives, use of relevant comparators, and evaluation of relevant outcomes and treatment heterogeneity. Should these principles be found appropriate and useful, CER studies should be audited for adherence to them and monitored for their impact on care management, patient relevant outcomes and clinical guidelines.

A systematic review of coverage decision-making on health technologies-evidence from the real world

OBJECTIVE

Quantitative analysis of real-world coverage decision-making offers insights into the revealed preferences of appraisal committees. Aim of this review was to structure empirical evidence of coverage decisions made in practice based on the components 'methods and evidence', 'criteria and standards', 'decision outcome' and 'processes'.

METHODS

Several electronic databases, key journals and decision committees' websites were searched for publications between 1993 and June 2011. Inclusion criteria were the analysis of past decisions and application of quantitative methods. Each study was categorized by the scope of decision-making and the components covered by the variables used in quantitative analysis.

RESULTS

Thirty-two studies were identified. Many focused on pharmaceuticals, the UK NICE or the Australian PBAC. The components were covered comprehensively, but heterogeneously. Seventy-two variables were identified of which the following were more prevalent: specifications of the decision outcome; the indications considered for appraisal, identification of incremental cost-effectiveness ratios, appropriateness of evaluation methods, type of economic or clinical evidence used for assessment, and the decision date.

CONCLUSIONS

Research was dominated by analysis of decision outcomes and appraisal criteria. Although common approaches were identified, the complexity of coverage decision-making - reflected by the heterogeneity of identified variables - will continue to challenge empirical research.

Evidence, research, and clinical practice: a patient-centered framework for progress in wound care

Traditional criteria used in selecting wound care interventions are being slowly replaced with an evidence-based practice approach. The value of such an approach for providing optimal care has been established, but the definition of evidence-based care and the process used to generate evidence continue to evolve. For example, the role of studies developed to demonstrate efficacy, randomized controlled trials, the value of effectiveness studies designed to evaluate outcomes in real world practice, and the use of disease-oriented (interim) study outcomes for wound care research, such as reduces wound fluid or improves granulation tissue formation, have been topics of international conversations and consensus documents. In addition, the use in some clinical studies and most systematic study reviews of ingredient or characteristic-based categories to group products that may not share a common operational definition of how they function has led to a high variability in outcomes, resulting in inconclusive or low-level evidence. These concerns and debates, along with their influence on practice, may cast doubt on the value of evidence-based practice guidelines for some clinicians, slowing their rate of implementation, and extending the discussion about definitions of evidence-based care and the relative merits of various research designs. At the same time, amid growing concerns about medical device safety, clinicians must answer 3 questions about an intervention and its related products or devices in order to provide safe and effective care: (1) Can it work? (2) Does it work? (3) Is it worth it? Reviewing current knowledge about wound care, wound treatment modalities, and the basic principles of research within the existing framework of questions to be answered suggests a clear path toward obtaining much-needed evidence. In wound care, using clearly defined processes to study patient-centered outcomes (eg, quality of life, complete healing) and only product groupings that meet an operational definition of functioning (eg, moisture-retentive) will help clinicians decide whether an intervention can work and does work and whether the value of the clinical and economic benefits is greater than the potential harm and cost.

CAN WE RELIABLY BENCHMARK HEALTH TECHNOLOGY ASSESSMENT ORGANIZATIONS?

Objectives: In recent years, there has been growth in the use of health technology assessment (HTA) for making decisions about the reimbursement, coverage, or guidance on the use of health technologies. Given this greater emphasis on the use of HTA, it is important to develop standards of good practice and to benchmark the various HTA organizations against these standards.

Methods: This study discusses the conceptual and methodological challenges associated with benchmarking HTA organizations and proposes a series of audit questions based on a previously published set of principles of good practice.

Results and Conclusions: It is concluded that a benchmarking exercise would be feasible and useful, although the question of who should do the benchmarking requires further discussion. Key issues for further research are the alternative methods for weighting the various principles and for generating an overall score, or summary statement of adherence to the principles. Any weighting system, if developed, would need to be explored in different jurisdictions to assess the extent to which the relative importance of the principles is perceived to vary. Finally, the development and precise wording of the audit questions requires further study, with a view to making the questions as unambiguous as possible, and the reproducibility of the assessments as high as possible.

Health economics and outcomes research within drug development: challenges and opportunities for reimbursement and market access within biopharma research

Healthcare decision makers who determine funding for new medical technologies depend on manufacturers to provide evidence of the technology's efficacy, safety and cost-effectiveness. Constrained budgets and increasing reliance on formal health technology assessment (HTA) have created an abundance of external hurdles that manufacturers must navigate to ensure successful product commercialization. These demands have pushed pharmaceutical companies to adjust their internal structures to coordinate generation of appropriate evidence. In this article we summarize internal and external opportunities for manufacturers to establish a foundation of evidence for successful market access, starting in Phase I of development and continuing throughout the post-approval product lifecycle.

Medicare's policy on carotid stents limited use to hospitals meeting quality guidelines yet did not hurt disadvantaged

Medicare began covering the use of carotid stents to treat arterial blockages in 2005 under an innovative policy requiring hospitals to meet quality-of-care benchmarks before seeking reimbursement. By restricting carotid stent provision to a smaller subset of US hospitals than those typically adopting new cardiovascular technologies, this policy could have disproportionately reduced the availability of this technology for minority, low-income, and rural patients. Such patients are often served by hospitals less able than others to meet increasingly stringent quality requirements. However, our analysis of hospitals that provided stents during 2005-07 demonstrated that although 21-38 percent fewer hospitals offered stents than offered other types of interventional cardiovascular procedures, such as heart bypass grafts, stents were no less available in localities with substantial poor, black, or rural populations than they were in other areas. Our study provides important evidence that the carotid stent coverage policy met its goal of limiting the adoption of the technology by hospitals that weren't well prepared to provide it-while still maintaining equitable availability of the technology. Therefore, it may be a useful model for future Medicare coverage decisions.

Comparative effectiveness research under the Patient Protection and Affordable Care Act: can new bottles accommodate old wine?

The Patient Protection and Affordable Care Act (PPACA), as amended by the Health Care and Education Reconciliation Act of 2010, initiated comprehensive health reform for the healthcare sector of the United States. PPACA includes strategies to make the American healthcare sector more efficient and effective. PPACA's comparative effectiveness research initiative and the establishment of the Patient-Centered Outcomes Research Institute are major strategies in this regard. PPACA's comparative effectiveness research initiative is one in a long line of federal initiatives to address the rising costs of healthcare as well as to obtain better value for healthcare expenditures. The key question is whether the governance and design features of the institute that will oversee the initiative will enable it to succeed where other federal efforts have faltered. This Article analyzes the federal government's quest to ensure value for money expended in publically funded healthcare programs and the health sector generally. This Article will also analyze what factors contribute to the possible success or failure of the comparative effectiveness research initiative. Success can be defined as the use of the findings of comparative effectiveness to make medical practice less costly, more efficient and effective, and ultimately, to bend the cost curve.

What is evidence?

The assumption that comparative effectiveness research will provide timely, relevant evidence rests on changing the current framework for assembling evidence. In this commentary, we provide the background of how coverage decisions for new medical technologies are currently made in the United States. We focus on the statistical issues regarding how to use the ensemble of information for inferring comparative effectiveness. It is clear a paradigm shift in how clinical information is integrated in real-world settings to establish effectiveness is required.

Chronic conditions account for rise in Medicare spending from 1987 to 2006

Medicare beneficiaries' medical needs, and where beneficiaries undergo treatment, have changed dramatically over the past two decades. Twenty years ago, most spending growth was linked to intensive inpatient (hospital) services, chiefly for heart disease. Recently, much of the growth has been attributable to chronic conditions such as diabetes, arthritis, hypertension, and kidney disease. These conditions are chiefly treated not in hospitals but in outpatient settings and by patients at home with prescription drugs. Health reform must address changed health needs through evidence-based community prevention, care coordination, and support for patient self-management.

The process of updating the National List of Health Services in Israel: Is it legitimate? Is it fair?

Objective:The Israeli National Health Insurance Law stipulates a National List of Health Services (NLHS) to which all residents are entitled from their HMOs. This list has been updated annually for almost a decade using a structured review and decision-making process. Although this process has been described in detail in previous papers, none of these have fully addressed legitimacy and fairness. We examine the legitimacy and fairness of the process of updating the NLHS in Israel.

Methods:We assessed the priority-setting process for compliance with the four conditions of accountability for reasonableness outlined by Daniels and Sabin (relevance, publicity, appeals, and enforcement). These conditions emphasize transparency and stakeholder engagement in democratic deliberation.

Results:Our analysis suggests that the Israeli process for updating the NLHS does not fulfill the appeals and enforcement conditions, and only partially follows the publicity and relevance conditions, outlined in the accountability for reasonableness framework. The main obstacles for achieving these goals may relate to the large number of technologies assessed each year within a short time frame, the lack of personnel engaged in health technology assessment, and the desire for early adoption of new technologies.

Conclusions:The process of updating the NLHS in Israel is unique and not without merit. Changes in the priority-setting process should be made to increase its acceptability among the different stakeholders.